11 Jul 2018

July 11, 2018

Written by REBEL EM
Background: The most feared complication in the clinical course of children with diabetic ketoacidosis (DKA) is the development of cerebral edema. Cerebral edema is rare (<1%) but is the leading cause of death in pediatric DKA. Many of the details about the risk factors as well as the mechanisms leading to DKA related cerebral edema are not well understood. Before we review the recent, groundbreaking study by Kupperman et al (1), examining the relationship between intravenous fluid content and rate of fluid administration in the development of DKA related cerebral edema, it’s important that we review the associated risk factors as well as the proposed mechanisms. It is important to know that the available data we are about to review comes from retrospective studies as well as case reports and case series and not from randomized control trials.
Medical Categories: Pediatrics
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2 Jul 2018

July 2, 2018

Written by REBEL CME, REBEL Crit
Refractory Hypoxemia: Now maybe you have intubated a patient secondary to hypoxemic respiratory failure who is at high risk for the development of acute respiratory distress syndrome (ARDS). These patients, and really all patients, with exception of severe obstructive disease, I set up the ventilator to deliver 6mL/kg based on ideal body weight (not actual weight). Regardless if this is a pediatric or adult patient, I am setting up the ventilator to target 6 mL/kg of IBW. I can accomplish this with either pressure mode, where you set the pressure, but closely monitor the tidal volumes the patient is receiving.
Medical Categories: Thoracic and Respiratory
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22 Jun 2018

June 22, 2018

Written by REBEL CME, REBEL Crit
Obstructive Physiology: Setting up the ventilator for a patient with severe obstructive physiology like asthma or COPD is almost a completely opposite strategy compared to the patient with severe metabolic acidosis. They both have problems with ventilation (removal of carbon dioxide), but for the patient with obstructive disease it takes a very long time to expire due to inflammation and bronchoconstriction.  Instead of setting a high respiratory rate to blow off more CO2 like our severe metabolic acidosis patient, here, you want to set a low respiratory rate to give your patient time to empty more effectively.
Medical Categories: Thoracic and Respiratory
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18 Jun 2018

June 18, 2018

Written by REBEL CME, REBEL Crit
Before I set up the ventilator, I consider if my patient has one of the following 3 physiologic processes: severe metabolic acidosis, an obstructive process (Asthma or COPD), or refractory hypoxemia. If my patient doesn't fit into one of these 3 categories then I will default to placing them in the refractory hypoxemia category (Part 5), which is simply a lung protective strategy that will be appropriate for patients. In this part we will discuss setting up your ventilator for the patient with a severe metabolic acidosis.
Medical Categories: Thoracic and Respiratory
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18 May 2018

May 18, 2018

Written by REBEL CME, REBEL Crit
In part 1, we discussed that the ventilator can deliver 3 types of breaths: controlled, assisted or spontaneous breaths. These breaths can be delivered either by a set pressure or a set tidal volume. Then we closed with a discussion of the common ventilator modes, which is simply just combining all these types of breaths together. There are many aspects to consider in post-intubation management such as hemodynamic variations, analgesia & sedation, confirmation of the correct position of your endotracheal tube, and setting up the ventilator based on your patients physiology. Too often physicians pay little or no attention to how our amazing respiratory therapists set up the ventilator. Respiratory therapists have expertise in setting up, weaning and trouble-shooting the ventilator, but clinicians need to communicate important clinical physiologic information and their goals for their patient on mechanical ventilation. If you don't feel comfortable setting up the ventilator at this point you at the very least need to communicate with your respiratory therapist when the ventilator is being set up.
Medical Categories: Thoracic and Respiratory
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